Physicians’ Guide to Direct Billingregarding this guide. Contact the New Brunswick Medical Society (NBMS) by mail at 21 Alison Blvd, Fredericton NB E3C 2N5; by telephone at 506-458-8860

Physicians’ Guide toDirect BillingIncludes revisions up to January 2019(français au verso)

IntroductionThis guide to direct billing is designed to provide guidelines and information tohelp New Brunswick physicians carry out the direct billing process in an efficientand professional manner.

It was produced by the Economics Committee of the New Brunswick MedicalSociety (NBMS) in consultation with the Section Liaison Representatives andapproved by the Board of Directors.

There are a number of ways by which you can contact the NBMS should yourequire clarification or further information, or have suggestions or commentsregarding this guide.

Contact the New Brunswick Medical Society (NBMS) by mail at 21 Alison Blvd,Fredericton NB E3C 2N5; by telephone at 506-458-8860 or 1-800-661-2001;or by e-mail at [email protected].

The Guide is also available in the "Members Only" section of the New BrunswickMedical Society website. The address is: www.nbms.nb.ca

Table of ContentsWhat services can be billed directly to the patient? . . . . . . . . . . . . . . . . . . . .2Ethical considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Uninsured services and suggested fees . . . . . . . . . . . . . . . . . . . . . . . . . . .4

• Unit values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4• Sessional rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5• Itemized fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

1. Third Party Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52. Requested Forms/Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53. Medical Legal Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64. Administrative-Technical Services . . . . . . . . . . . . . . . . . . . . . . . . . . .75. Clinical Services (Selected) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86. Court Ordered Psychiatric Assessments . . . . . . . . . . . . . . . . . . . . . . .9

Access Request and PHIPAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Harmonized sales tax and uninsured services . . . . . . . . . . . . . . . . . . . . . .12The direct billing process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Keeping patients well-informed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Receiving payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Accounts receivable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Collecting accounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Sample collection timetable (120 day schedule) . . . . . . . . . . . . . . . . . . . . .18Sample collection letters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Accounts gone bad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Appendix A - Agreement between the New Brunswick MedicalSociety and WorkSafeNB Regarding Payment Arrangements forMedical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Appendix B – Billing for patients from the Canadian Armed Forces and Royal Canadian Mounted Police (RCMP) . . . . . . . . . . . . . . .28Appendix C - Annual Administration Plan . . . . . . . . . . . . . . . . . . . . . . .29Appendix D - Form letters, ie. Medical Chart Transfer, Medico-Legal Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Appendix E - Preparing Medico-Legal Reports: Guidelines for Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

1JANUARY 2019 PHYSICIANS’ GUIDE TO DIRECT BILLING

What Services Can be BilledDirectly to the Patient?A service may be billed directly to the patient if it is not covered by Medicare orsome other insuring body. Using Medicare as the frame of reference, there arethree scenarios under which the physician may bill the patient directly: anuninsured service; an uninsured patient; or the physician opts out of Medicare.These scenarios are described below:

• An uninsured service is one requested by an insured patient that is notincluded in the range of entitled services under New Brunswick Medicare. Acomplete list of uninsured services is located in the Medicare Physicians’Manual. The Medicare Physicians’ Manual also includes a list of itemizedsupplies and materials that are not insured.

It is important to note that any “third party” request is not insured by Medicare.• An uninsured patient is anyone who is not included as a beneficiary of the

Medicare System under the Medical Services Payment Act. Examples include:regular members of the Canadian Armed Forces; persons serving a term ofimprisonment in a penitentiary maintained by the Government of Canada; orinternational patients.

In addition to Medicare, the New Brunswick Medical Society has Agreements onfees with WorkSafeNB. Therefore, this Guide does not apply to WorkSafeNB.Rates that should be charged to WorkSafeNB are outlined in Appendix A.

• A physician may choose to opt out of Medicare. This can be done forindividual services, or completely. When a physician opts out, he/she mustadvise the patient in advance of providing the service. Medicare also statesthat the patient must be advised that the “patient is entitled to seek the servicesfrom another practitioner on an opted-in basis.” Regarding the fee charged tothe patient, two possibilities exist:a) A patient is charged an amount equal to Medicare. In this instance the

physician is required to complete a Medicare Claim Form and indicate theamount charged to the patient. The patient must certify this data on theclaim form in order to be reimbursed by Medicare.

b)A patient is charged an amount in excess of Medicare’s fee. In this instancethe physician is required to inform the patient that a fee above Medicare’srate is being charged. As a result, the patient waives all right toreimbursement by Medicare. Therefore, a patient must complete the“Patients Medicare Coverage Waiver” and the completed form must besubmitted to Medicare. By charging the patient an amount in excess ofMedicare’s fee, this service becomes an uninsured service; the patient isthus not entitled to any reimbursement from Medicare.

2 PHYSICIANS’ GUIDE TO DIRECT BILLING JANUARY 2019

Ethical Considerations When billing a patient directly, physicians must keep in mind ethicalconsiderations. Members should consider the following excerpts from the CMACode of Ethics:

1. Consider first the well-being of the patient. 2. Practise the profession of medicine in a manner that treats the patient with

dignity and as a person worthy of respect.13. Do not exploit patients for personal advantage.16. In determining professional fees to patients for non-insured services,

consider both the nature of the service provided and the ability of thepatient to pay, and be prepared to discuss the fee with the patient.

17. In providing medical services, do not discriminate against any patient onsuch grounds as age, gender, marital status, medical condition, national orethnic origin, physical or mental disability, political affiliation, race, religion,sexual orientation or socio economic status. This does not abrogate thephysician's right to refuse to accept a patient for legitimate reasons. . . . . .

In addition, the College of Physicians and Surgeons notes that there are several matterswhich may potentially lead to a claim of professional misconduct. They include:

• stipulating, charging, or accepting any fee that is not fully disclosed, fair andreasonable;

• charging a fee for an undertaking to be available to provide services to aspecific patient;

• charging a fee that is excessive in relation to the services performed;• failure to issue a statement or receipt when requested by a patient or their

authorized representative;• selling or assigning any debt owed to the member for professional services:

(but a member may accept a credit card to pay for professional services andmay make a general assignment of debts as collateral for a loan to financehis or her medical practice);

• refusing to render a medically necessary service unless payment of the wholeor part of the fee is received in advance of the service being rendered;

• refusing to provide professional services for a reason which, having regard toall the circumstances, would reasonably be regarded as discriminatory;

• charging a fee for services not performed. This does not include charging forthe cancellation of an appointment less than 24 hours before the appointmenttime; and

• knowingly submitting a false or misleading account or false or misleadingcharges for services rendered to a patient.


Uninsured Services and SuggestedFeesThe NBMS has historically (since Medicare) published a Guide to Unit Values. TheGuide has been incorporated into this document. In addition, the EconomicsCommittee has developed other specific recommended values to serve as a guideto billing for uninsured services.

The following suggested unit values, sessional rates, and itemized fees are not tobe construed as either maximum or minimum values. They are only a generalguide for services of average complexity. With the assistance of this guide, theindividual physician, dealing directly with his or her patient, can set a fair andreasonable value on services provided. The fees charged should reflect timeinvolved, your expertise, and the patient’s ability to pay. No physician is obligedethically or otherwise to follow the Guide; it is not binding on any physician andhe or she has the right to deviate from it.

You should review your fees annually to keep pace with inflation, changingconditions within your practice, and your growing expertise. Remember that it isimportant to discuss your fees with your patient prior to providing services. If yourpatient’s agreement to the fee is not obtained before the service is provided, he orshe is not obliged to pay.

Unit Values:These Unit Values must be multiplied by the units assigned to individual fees in theMedicare Physicians’ Manual to produce a dollar figure that may be charged tothe patient. The unit values are routinely updated on the basis of inflation andMedicare increases.

General Unit Value . . . . . . . . . . . . . . .$2.60

Radiology Unit Value . . . . . . . . . . . . . .$2.96

Anaesthesia Unit Value . . . . . . . . . . .$26.76

(Effective January 2019)


Sessional Rate:You may decide to either bill patients based on specific fees for services, or thetime required to provide a particular service.

Recommended Sessional Rate:

Specialist and Non-Specialist . . . . . . . . . . . . . .$290-$555/hr or part thereof.

Itemized Fees:

1. Third Party Examinations

1.1 Complete Physical Examination . . . . . . . . . . . . . . . . . . . . . . . .$85-$135(including Camp or School Physical)

1.2 Complete Disability Examination(a variable fee may be charged in addition depending on the complexity of any required report) . . . . . . . . . . . . . . . . . . . . . . . .$135

1.3 Insurance physical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$135(an additional fee may be charged depending on the complexity of any required report)

1.4 Driver’s Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$85-$135(fee may vary depending on complexity, ie. NB vs. American, government vs. insurance company)

1.5 Periodic Industrial Health Physical (ie. pre-employment physical) . . . . . .$170 (an additional fee may be charged depending on the complexity of any required report)

2. Requested forms/reports

2.1 Disability Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$58-$85

2.2 Certificates of short term illness or disability . . . . . . . . . . . . . . . .$16-$26

2.3 Third party requested letters/questionnaires on patient attended, including insurance company assessment . . . . . . . . . . . . . .$170 +$1.00/pg photocopy(an additional fee may be charged depending on the complexity of any required report)

2.4 SEP (Single Entry Point) Assessment . . . . . . . . . . . . . . . . . . . . .$58-$115


Forms required for prescription drug insurance:

2.5 Drug Coverage Special Authorization Forms andQuantity Ceiling Override . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$16-$42

2.6 Complete disability report, including Revenue CanadaDisability Forms (follow-up requests may also be billed) . . . . . . . . . . . . . . $135

2.7 Canada Pension Disability Form . . . . . . . . . . . . . . . . . . . . . . . . . .$135($85 paid by Government, $45 paid by applicant)

2.8 Proof of Child Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . .$16-$26

2.9 Red Cross or Other Third Party Equipment Form . . . . . . . . . . . . . .$16-$26

2.10 Blue Cross or Other Third Party Form (i.e. authorization for foot care) . . . . . . . . . . . . . . . . . . . . . . . . . . . .$16-$26

3. Medical Legal Services

Physicians should always discuss and confirm arrangements with the lawyer inadvance. Note that these fees are ultimately and directly passed on to thepatient as an add-on to the lawyer’s fees. Rates may vary based on thecomplexity of the report.

A lawyer’s request for a medical report should always include the patient’s consentto the transfer of information. For further information, members can consult the"Lawyer/Physician Interaction Guidelines". Copies of the Guidelines are availablefrom the Society.

3.1 Medical legal report, with opinion . . . . . . . . . . . . . . . . . . . .$290-$555 extended or complicated . . . . . . . . . . . . . . . . .I/C (independent consideration)

3.2 Medical legal office briefing by arrangement between physician and lawyer (not involving court appearance) . . . . . . . . . . . . . . . . . . . . . . . . . .$290-$555/hr or part thereof


3.3 Court appearance (including waiting time). . . . . .. $290-$555/hr or part thereof (minimum 3 hours)

3.4 Cancellation of Court Appearance (without 1-2 working days notice) . . . . . . . . .$290-$555/hr (minimum 3 hours)

3.5 Copying of file on request of lawyer . . . . . . . . . . . . . . .$58 + $1.00/pg

3.6 Travel and Preparation Time . . . . . . . . . . . . .$290-$555/hr or part thereof

Note: The above fees may also apply to services performed on behalf of theCrown.

4. Administrative-Technical Services

4.1 Medical advice by letter . . . . . . . . . . . . .$290-$555/hour or part thereof

4.2 Medical advice by telephone, fax or electronic media . . . . . . . . .$37-$58

4.3 Prescription renewal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$16-$37(Charges for prescription renewal apply to phone requests, requests for non-present family member, etc. This fee should not be charged in conjunction with aMedicare office visit)

4.4 Missed appointment . . . . . . . . . . . . . . . . . . . . . . . . . .30%-100% of fee

4.5 Rebooking tests at hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . .$16-$26

4.6 Travel . . . . . . . . . . . . . . . . . . .$0.55/km plus hourly rate per quarter hour

4.7 Hospital/Regional Health AuthorityCommittee Work . . . . . . . . . . . . . . . . . . . . .$290-$555/hour or part thereof

4.8 Medical Supplies/Equipment notincluded as part of insured service . . . .cost (including carrying cost and storage)

4.9 Fax transmission/receive (+ telephone charges) . . . . . . . . . . . . .$1-$2/pg

4.10 Return NSF cheque . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$25

4.11 Annual Administration Fee . . . . . . . . . . . . . . . . . .Please see Appendix C


4.12 Medical records transferor chart summary . . . . . . . . . . . . . . . . . .$42-$58 plus $1.00/pg photocopy

NOTE: In June 1992, the Supreme Court of Canada rendered a judgementdealing with a patient’s right of access to his/her medical records compiled in theoffice of a physician. It is important to note that this decision clearly states thatalthough a physician may charge for transferring a patient’s records, a physiciancannot impede a patients' right to access their records based solely on theirinability to pay.

In addition, physicians should keep in mind that the health needs of the patientcan often be addressed without transferring or copying the entire medical record.This should be discussed with the patient, and the patient should be advised of thefee that will be charged, before the physician proceeds with any copying.

5. Clinical Services (Selected)

5.1 Newborn Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . .$115-$165

5.2 Injectables (includes flu shots, cortisone, etc.) + medication costs . . .$16-$26

5.3 Vasectomy Reversal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$815

5.4 Subsequent Injections for Impotence . . . . . . . . . . . . . . . . . . . . . . . . .$58

5.5 Nursing Services provided in a Physician's Office (Doctor not in attendance)Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$16Urinalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$16Blood Sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$16Hemoglobin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$16Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$16ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$32Spirometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$21Peak Flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$16

5.6 Travel Consultation (single) . . . . . . . . . . . . . . . . . . . . . . . . . .$115-$135

Follow-up Consultation/Injection . . . . . . . . . . . . . . .$42-$74 + $11/injection


6. Court Ordered Psychiatric Assessments

An agreement in September 2010 between the NBMS and the Department ofJustice and Consumer Affairs, provides for the remuneration of psychiatrists whoperform forensic psychiatric court ordered assessments. The agreement is in effectfrom April 1, 2010 until March 31, 2014. Rates remain in effect until such timethat a new contract is negotiated.

RemunerationIn-patient Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$2,601(Restigouche Hospital Center or other)Out-patient Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$1,378.53(Community Mental Health Clinic or other)Travel time to/from Court . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$200/hrCourt Attendance Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$200/hr

Travel Expenses: Travel expenses are paid at Government of New Brunswickrates. The present rates are:

Hotel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(provide receipt) Kilometrage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$0.41/kmMeals:

Breakfast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$7.50Lunch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$10.50Supper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$19.50



Access Request and PHIPAAThe Personal Health Information Privacy and Access Act (PHIPAA) came into effecton June 2009 and provides a set of rules that protect patient privacy and theconfidentiality of your personal health information. The Act also ensures thatinformation is available, as needed, to provide health services to those in needand to monitor, evaluate and improve the health system in NB.

Physicians are custodians of patient’s personal health information and as such maybe subject to access requests for patients. The Act states that an individual has aright, on request, to examine or review a copy of his or her personal healthinformation maintained by a custodian. The custodian must respond to the requestno later than 30 days after receiving the request.

Under the Act, a custodian shall permit an individual to examine a record free ofcharge, and may, in accordance with the regulations, require an individual to payto the custodian a fair and reasonable fee for search, preparation, copying anddelivery of courier services. If a patient formally authorizes another individual, inwriting, to act as their agent in making a PHIPAA request (ie: a lawyer acting onbehalf of a patient), a physician must comply with that request. In responding to aPHIPAA request from a patient, or from an individual formally authorized to act asthe agent of the patient, physicians are required to limit their fees to those set outin the Regulation.

Patient requestshealth informationfrom the custodian

The custodianresponds to therequest within

30 days.

The fees are set out in Regulation as follows:

Search and Preparation Fees $15 per half hour beyond the first 2 hours

Copying Fees $0.25 for each page copied

Computer Programming and Data $10 for each 15 minutes of internalProcessing Fees programming or data processing or

the actual cost of programming and data processing

Mail and Courier Delivery No fee is payable for mailing a request.If courier delivery costs are necessary, the Custodian may charge the actual cost of the courier delivery.

The Custodian may waive all or part of these fees.

The Personal Health Information Privacy and Access Act (PHIPAA) and itsRegulations are available on the Government of NB website under the Departmentof Health/Legislation/Personal Health Information Privacy and Access.


Fee forsearch

Fee for preparationand copying

Fee fordelivery of

courierservices

Harmonized Sales Tax andUninsured ServicesAccording to the Canada Revenue Agency (CRA), “where the physician is directlyinvolved in the examination/treatment of the patient (ie. examination and reportsto WorkSafeNB, a life insurance company, a lawyer, provides a sick certificateetc.) this service will be classified as a medical service and will be HST exempt -whether it is paid for by the patient or the third party.”

“However, if the physician is only involved in referring documents, providing anexpert opinion in writing or personally, ie. functions as the expert witness only, thephysician will be required to bill for, collect and transmit the 15% HST.” Mostphysicians, though, will be affected by the “small supplier” clause; if servicessubject to HST total less than a designated amount, you need not collect or passon the HST.

From the time the GST and later HST were introduced in New Brunswick, it wasunderstood that Independent Medical Examinations (IME's) were a taxable supply.Billings to insurance companies, lawyers, and others for IME's were to includecollection of GST/HST, unless the small supplier rules applied.

However, in late 2006, a GST/HST Policy Statement was released by CRAwhich contained their current view that most IME's may be exempt from GST/HST.

The 2013 Federal Budget introduced amendments to the Excise Tax Act, whichwhen implemented, will apply a new approach to the application of GST/HST touninsured services provided by physicians, retroactive to March 22, 2013. CRAwill be applying a new “purpose test” for the determination of GST/HSTexemption for Health Services.

The policy intent of these changes is still be finalized by CRA and FinanceCanada (FC).

Physicians are encouraged to discuss HST related issues with their ownaccountant.


The Direct Billing ProcessKeys to EfficiencyThe following procedural guidelines are provided to enable you to carry out thedirect billing process in a professional, efficient and timely manner:

• Establish and maintain a simple and clear office policy and procedure fordirect billing. To achieve this you should first determine:- Those services for which patients will be directly billed- The fees attached to those services- Any exemptions, such as seniors or low-income patients- Bookkeeping and collection procedures

Your office policy on direct billing must be specific and detailed so that your staffand your patients fully and clearly understand it. At the same time, it should allowsufficient flexibility to adapt to any unique or unexpected circumstances you mayencounter.

• Inform your staff of this policy and procedure, and keep them apprised of anychanges.

• Maintain up-to-date accounts.• Collect payments from patients at the point of service as often as possible.• Follow-up in an orderly and consistent manner.• Always discuss fees with your patients before providing the service.

Written GuidelinesPut your office policy in writing and distribute it to the staff.

In addition, you should schedule regular meetings to update and remind staffabout the direct billing process, answer any of their questions or queries, and togain feedback on their experiences with patients. This will help you to evaluate thesuccess of your policy and procedures. It will also aid you in identifying anyemerging problems before they become serious enough to negatively affect yourstaff or patients.


Keeping Patients Well-InformedMost difficulties between a physician and a patient arise from a lack of clearcommunication. Many patients simply do not realize that there are some services theGovernment does not pay for and they may become upset when presented with a bill.

To prevent this from happening, you must ensure that your patients are well-informed about uninsured services and your direct billing policy well inadvance of receiving treatments.

While posters displayed in your office may introduce your patients to the conceptof direct billing, they are not a substitute for more direct methods of informingpatients of your fees. It is recommended that patients be provided with aninformation sheet or booklet which states current fees.

Developing your Patient Information BookletA patient information booklet is an important guide to your practice which willbenefit your patients, your staff and you. Its purpose is to provide a written generaldescription of the scope of your practice as well as setting out guidelines on thedirect billing policy. Ultimately it will save you and your staff the time and troubleof repeating answers to commonly asked questions. Your patient informationbooklet should include:

General information


• Office hours• Telephone hours• Test or x-ray procedures and

availability

• Prescription refill instructions• After-hours procedures• Other office policies

Direct billing information• A brief description of the direct billing concept.• Services that are billed directly by you.• Procedures for third party claim forms.

It is not advisable to list your fees in the booklet. These fees will require periodicupdating while the rest of the information in the booklet remains current. Feesshould be listed on a separate typewritten sheet which can be easily andinexpensively revised. Your patient information booklet may be produced throughdesktop publishing and good quality photocopying. The information contained inthe booklet is the important factor, not its appearance.

Receiving PaymentOne of the most important aspects of receiving payment for services you provide isto maintain an up-to-date reporting and billing system. The importance of thissystem is amplified when you deal with third party agencies that often makepartial initial payments.

You may want to consider offering a payment plan to your patients whom you billdirectly. Remember, the easier you make it for the patient to pay, the higher yourcollection success rate will be. You may also want to consider accepting creditcards. Start-up and operating information is available from your bank.

The longer an account remains unpaid, the more difficult it becomes to receivepayment, and the account actually decreases in value. According to MD PhysicianServices the real value of a dollar owed becomes:


$0.90 .... after two months

$0.67 .... after six months

$0.45 .... after one year

$0.23 .... after two years

$0.14 .... after three years

$0.01 .... after five years

Accounts ReceivableKeeping Track of Your AccountsTo begin with, you will need appropriate receipts which state “professionalservices rendered,” the type of service, and fee, and invoices for those whocannot immediately pay.

Sample Invoice

Invoice Current PreviousNumber Date Charge Payment Balance Balance

XXX XXX XXX XXX XXX XXX

Invoiced to: _________________________________________________________________________________________________________________________

Amount: __________________________________________________________

For professional services rendered (Description of Service) _____________________________________________________________________________________________________________________________________________________

Your name, address, telephone number _________________________________

• The (charge, payment, previous balance, current balance) section appears ona one-write or similar invoice. It gives you and your patient, an instant pictureof the patient’s account.

• On a receipt, the invoice number is replaced with receipt number, and“invoiced to” is replaced with “received from”.

• You will also require a ledger to provide you with an accurate daily picture ofthe status of your accounts.

There are a variety of computer programs and apps which will print a receipt andmake all the appropriate bookkeeping entries. The staff member who does thebilling must ensure each statement is complete and accurate. An incomplete orinaccurate bill not only creates more work for you and your staff, but also givesdelinquent patients one more excuse not to pay.


Collecting AccountsWhile a payment plan encourages payment from your patients, you must have anorganized system to successfully collect.

Accounts should normally be billed on a 30/60/90 day schedule. Paymentshould be due at time of service - interest charges of 1.5% per month can beapplied to outstanding accounts after 30 days. If payments are not being made,letters and telephone calls by staff should be used to prompt patients into paying.

The staff person making the telephone call should ask if the payment was made. Ifnot, a verbal commitment to pay should be obtained. The staff member shouldrestate the commitment by telling the patient you will be expecting payment by thedate promised.

Because it can be easy to forget what was said during a busy day, written recordsof the calls should be kept.


Interest charges

1.5% per monthcan be applied to

outstanding accountsafter 30 days

Sample Collection Timetable –120 day scheduleProcedure Time Period Step

Send patient statement. Month service is January Billingrendered

Send patient statement with first Month after February Billing letter reminding patient this is a "Reminder"second statement.

Problem-solving call to patient. Prior to mailing of mid-March Phone CallGoal to secure commitment of March bill "Education"payment; arrange payment plan; determine if patient has a hardship or is dissatisfied with service.

If you did not reach patient by Second month March Billing phone or have not received after service "Letter #2"promised payment, send the second letter.

Phone patient and ask for a Prior to mailing of mid-April Phone Call definite dollar amount and date. April bill "Persuasion/Render problem-solving Information"assistance if necessary OR you may have to deal with a "broken promise to pay".

Send patient statement and last Third month after April Billing letter. You may wish to phone a service "Final Letterpatient several days after mailingthis letter ... some offices do.

If payment hasn’t been received Fourth month after May Turn accountand you are certain the patient service overis not dissatisfied with the service, send the account to a collection agency.



Sample Collection LettersTo follow are a few sample collection letters which may help you develop yourown format:

First Reminder:

Dear Patient name,

Your payment of $XX hasn’t beenreceived by our office. If there is anerror in your statement, please call meso that we can correct it. If not, pleasesend your cheque today so we cankeep your account up to date.

Sincerely,

Signature & title of staff memberresponsible for billing

FINAL Reminder:

Dear Patient name,

This is our third try to help you settleyour past-due account of $XX. You areobliged to pay your accounts onceyou have said you will.

Please call this office within 10 daysso that we can agree on a plan tosettle your account. If not, we will haveto turn it over to a collection agency.

Sincerely,Physician’s Signature

Second Reminder:

Dear Patient name,

Payment for your bill of $XX is now_____weeks past due. If there is someproblem, call me today so we candiscuss it. If not, please send yourcheque so we can keep your accountcurrent and avoid collection action.

Sincerely,Signature & title of staff memberresponsible for billing

A copy of the patient’s accountstatement should be included witheach letter. While specifying dates ofpast correspondence in the final letteris optional, you should keep file copiesof all letters and telephone logs. Thisprovides you with an accurate recordof past efforts and will be helpful to acollection agency should you need touse one.

You may wish to send your finalreminder via registered mail to ensurethe patient receives it.

Accounts Gone BadCollecting Overdue PaymentsNo matter how generous a payment plan you provide, some patients willdeliberately try to avoid paying and you will need to take collection action. This isa fact of business life.

Before taking collection action, have your staff member telephone the patient tofind out why he or she is not paying. If the patient is genuinely dissatisfied with theservice or undergoing unexpected hardship, it may be better for you in terms ofgoodwill to write off the bill.

If dissatisfaction with the service or hardship is not the case, a collection agencymay be your preferred route. It is not acceptable for a physician to sell a debt to acollection agency. The agency must work for a percentage of the fee that is beingcollected. The ultimate control of the debt must remain with the physician.

While you can realistically expect an agency to collect only a portion of youroutstanding accounts, the fact that an agency has been called indicates to apatient that, like any other business, yours will not tolerate delinquent accounts.

You should wait no longer than 120 days before turning the account over to acollection agency. Waiting too long makes the agency’s job more difficult andallows the outstanding amounts to decrease in value (see Receiving Payment,page 15).

Always check references when selecting an agency. You need one that is firm indealing with delinquent accounts, but your professional reputation is too valuableto retain an agency that employs “borderline” collection tactics. Physicians areconsidered to remain ethically responsible for the conduct of the agency during thecourse of debt collection.


Once you turn an account over to an agency it becomes the agency’s job tocollect the account, and you should no longer contact the patient about it.

As a final step, you may wish to take a delinquent patient to small claims court. Toinitiate a small claims action, you, or one of your staff, must first file a summonsform at a provincial court house. In order to file, you will have to provide thedefendant’s name, address, amount of claim and location of service. Once theform is completed, a court clerk sets a court date. It is not essential that you attendthe court hearing. A member of your staff can do so on your behalf.

The defendant must be informed of your action prior to the court date. You mustensure the defendant is personally served the summons. You can do this bypersonal delivery or by double-registered mail. Another option is to have a sheriffserve the summons, but you must pay the sheriff’s fee. If the court, however, rules inyour favour, you are entitled to the amount owing plus your costs of the action.


Physician or staff files asummons form

A court clerk sets a courtdate

The defendant is personallyserved the summons

Appendix AAgreement between the New Brunswick MedicalSociety and WorkSafeNB Regarding PaymentArrangements for Medical ServicesThe unit values listed below are to be applied to the Medicare Physicians Manualas follows:

Unit Values

October 1, 2018

Anaesthesia $24.52

General Practice $2.40

Specialist $2.48

Note: These rates do not include the Early Reporting Bonus

These rates will be automatically adjusted annually by the percentage change inthe “All Items” Consumer Price Index (CPI) for Canada.

All other non-Medicare Fee Schedule items in the WorkSafeNB contract (ie. earlyreporting fee payments for denied claims, acupuncture, etc.) remain part of thenew agreement and will be adjusted annually.

Early Reporting Bonus (ERB)

There shall be an early reporting bonus of 20% for all services for which a reportis received by WorkSafeNB within 5 working days of the service.

The ERB also applies to anaesthesia and surgical assist services, when the surgeonsubmits an operative report. There is no need for the physician to include the ERBon the physician billing form; the bonus will be automatically incorporated by theWorkSafeNB processing system. When fees are adjusted by the ERB, the amountpayable will be subject to "rounding".


To facilitate early reporting, physicians can fax reports toll-free to 1-888-629-4722 (when faxing, no need to mail reports). The toll-free line forphysician inquiries is 1-877-647-0777.

Payment for Services Where a Claim is Denied or Not Created

WorkSafeNB shall pay a fee of 33% of the General Practice office visit fee for theinitial office visit/service provided for claims which are subsequently denied byWorkSafeNB, where the employer is not required to be registered withWorkSafeNB, or which does not result in an established claim, provided that thephysician submits a Form 8 – Initial Report of Accident – and a “Worker’s Reportof Injury” which is completed and signed by the worker.

WorkSafeNB shall provide notification, to the physician, of the acceptance orrejection of such a claim.

Opioid Reporting Feei) The rate will be two (2) times the appropriate office visit feeii) eligible for early reporting bonusiii) no additional visit fee payable, unless there is a new report with

new/additional findings

Fees for Other Services

Where an item, treatment or procedure is not listed under the Unit Values orIndividual Fee Items Sections above, WorkSafeNB shall pay for those servicesgenerally covered by WorkSafeNB, based on the units as set out in the MedicarePhysician’s Manual, as updated from time to time upon receipt of notice fromMedicare and the unit value contained in this agreement.

Where WorkSafeNB requests an independent consultation and assessment from aphysician and where WorkSafeNB and the physician agree the case iscomplicated, and a timely report is necessary, WorkSafeNB may pay a rate twotimes the rate of the negotiated rate at the time of the request.


Fee Premium for After-Hours Service

The WorkSafeNB after-hours emergency premium for consultations, anaesthesiaand procedures apply as follows:

The 100% premium applies:• Between the hours of midnight and 06h00 every day.• All day on weekends (Saturday & Sunday) and holidays.

The 50 % premium applies:• Between 18h00 and midnight weekdays• Between 06h00 and 08h00 weekdays

The After-hours premium does not apply to regularly scheduled hours of operation,such as regular weekend or evening office/clinic hours.

Reporting• Reporting shall be on a form as provided by WorkSafeNB or other form

acceptable to WorkSafeNB. WorkSafeNB may withhold payment for anyreport submitted under this agreement that is illegible and/or incomplete.Such reports will need to be corrected and re-submitted for payment.

• For consultation and surgery reports and emergency room contacts,WorkSafeNB will provide access to a phone-in transcription service if there issufficient demand for this service.

• For office visit services (not consults) which involve more than one claim for aclaimant, the physician will provide separate reports for each claim andWorkSafeNB will pay separately for each service and report provided.

Frequency of Office Visits • In the acute injury phase, WorkSafeNB encourages the physician to follow

the claimant frequently to ensure the earliest possible return to work date evenat lighter job demands.

• When a claimant has stabilized medically, by virtue of the physician andWorkSafeNB agreeing the claimant has stabilized, the parties agree thatWorkSafeNB will pay for not more than one routine office visit every secondmonth.

• Should the claimant’s medical status subsequently change, the physicianwould submit a Form 10 noting how the medical status has changed.WorkSafeNB will pay for office visits as required until such time as theclaimant stabilizes again.

• WorkSafeNB will pay for all patient-initiated visits related to the claim.


Other Services Compensated by WorkSafeNB

Conversion of non-Medicare Items

1.Items not covered in the Medicare Physician’s Manual are paid at a percentageor multiple of the office visit fee.

1.1. Acupuncture1.1.1. Fee code: W1010 – initial 10 minutes; W1011 – count of

additional 10 minutes1.1.2. Paid at: 100% of the office visit fee for the 1st 10 minutes and at

48% of the office visit fee for each additional 10 minutes to amaximum of 40 minutes

1.2. Telephone consultation between physician and employer to discuss returnto work and accommodation 1.2.1. Fee code: W1020 – initial 10 minutes; W1028 – count of

additional 10 minutes1.2.2. Paid at: 100% of the office visit fee for the 1st 10 minutes and at

48% of the office visit fee for each additional 10 minutes 1.2.3. Requirement for payment: completion of the Telephone

Consultation Form. The physician must provide the name of theemployer and the name of the person with whom they werespeaking

1.3. Telephone consultation between physician and WorkSafeNB1.3.1. Fee code: Initial 10 minutes – Case Manager: W1030,

WorkSafeNB Physician: W1031, Cadre Physician W1032;W1038 – count of additional 10 minute blocks

1.3.2. Paid at: 100% of the office visit fee for the 1st 10 minutes and at48% of the office visit fee for each additional 10 minutes

1.3.3. Requirement for payment: completion of the TelephoneConsultation Form. The form is generally completed byWorkSafeNB and forwarded to the physician for validation andsigning


1.4. Case management or WRC case conference requested by WorkSafeNB1.4.1. Fee code: Initial 10 minutes – Case Management: W1040,

WRC: W1041; W1048 – count of additional 10 minuteblocks; W1049 – round-trip in kilometres to attend caseconference

1.4.2. Paid at: 100% of the office visit fee for the 1st 10 minutes and at48% of the office visit fee for each additional 10 minutes. Travelto attend a case conference at a WorkSafeNB location is paidat the rate paid to WorkSafeNB non-bargaining staff

1.4.3. Requirement for payment: completion of the TelephoneConsultation Form. The form is generally completed byWorkSafeNB and forwarded to the physician for validation andsigning

1.5. Telephone consultation between physician and physiotherapist to discussfunctional capacity assessment and match with job demands,physiotherapist’s assessment and rehab plan and progress1.5.1. Fee code: W10501.5.2. Paid at: 100% of the office visit fee 1.5.3. Requirement for payment: completion of the Telephone

Consultation Form. The physician must provide the name of thephysiotherapist with whom they were speaking

1.6. Telephone consultation between family physician and specialist1.6.1. Fee code: W10601.6.2. Paid at: 100% of the office visit fee1.6.3. Requirement for payment: completion of the Telephone

Consultation Form. The physician must provide the name of thephysician with whom they were speaking

1.6.4. The family physician and the specialist would each submit aTelephone Consultation form. Both would be paid.

1.7. Telephone consultation between specialist and specialist1.7.1. Fee code: W10621.7.2. Paid at: 100% of the office visit fee 1.7.3. Requirement for payment: completion of the Telephone

Consultation Form. The physician must provide the name of thephysician with whom they were speaking

1.7.4. The family physician and the specialist would each submit aTelephone Consultation form. Both would be paid.


1.8. Opioid review report1.8.1. Fee code: W10701.8.2. Paid at: twice the office visit fee 1.8.3. No additional visit fee is payable unless there is a separate

report submitted with new or additional findings1.8.4. This service involves an office visit by the claimant to complete

the review and is therefore eligible for the early reporting bonus1.8.5. WorkSafeNB pays the Opioid Review Report fee when the

review is triggered by the pharmacy or by WorkSafeNB.WorkSafeNB will generally not pay the fee when the review isinitiated by the prescribing physician

1.9. Follow-up letter by specialist to family physician and/or patient1.9.1. Fee code: W10801.9.2. Paid at: the office visit fee 1.9.3. Requirement for payment: WorkSafeNB is copied on the follow-

up letter1.9.4. WorkSafeNB pays for the primary letter. WorkSafeNB does not

pay to generate copies to others.

1.10. Physician letter responding to a basic question from WorkSafeNB1.10.1. Fee code: W10901.10.2. Paid at: the office visit fee

Copying Medical Records: WorkSafeNB will pay a base rate of 70% of the feein the NBMS Guide to 3rd Party Billing plus 100% of the per page fee. Whenchanges are made to the fees in the NBMS Guide to 3rd Party Billing, theMedical Society will notify WorkSafeNB. Changes would come into effect 15working days after the Medical Society has verified that WorkSafeNB hasreceived the notice of change.


Appendix BBilling for patients from the Canadian ArmedForces and Royal Canadian Mounted Police(RCMP)

Canadian Armed Forces

Billing physician services for members of the Canadian Armed Forces is donethrough Medavie Blue Cross. Physicians must register on the Medavie Blue Cross’website to bill for their services to Canadian Armed Forces personnel.

The process takes approximately three weeks from the time of registration to thetime that physicians can bill. Once registered, physicians will receive a usernameand password by email, and can use that to bill for patients online, by using theappropriate Medicare codes multiplied by the General Unit Value found on page4 of this guide.

Information that physicians will need to bill Medavie Blue Cross for servicesrendered include the Canadian Armed Forces member’s personnel number andreferral information, if applicable.

Payments will either be mailed in the form of a cheque or transferred electronicallyat the choice of the physician. Physicians can alternately bill Medavie Blue Crossmanually on paper, although paper claims will not be paid as quickly as onlineclaims.

If you need to register for direct billing to Medavie Blue Cross, please visit theMedavie Blue Cross website at: https://www.medaviebc.ca, then click on the“For Health Professionals” Link at the top of the page.

*Medavie Blue Cross website and link information is subject to change.

RCMP

The Federal Government passed Bill C-38 in June of 2012 which contained aprovision that amends the Canada Health Act so that members of the RCMP areincluded in the definition of the ‘insured persons’. Members of the RCMP living inNB will now be covered under New Brunswick Medicare and physicians will billNB Medicare rates for members of the RCMP. This provision became effectiveApril 1, 2013.


Appendix CAnnual Administration PlanAn Annual Administration Plan offers patients the option of paying an AnnualAdministration fee to cover the cost of services not insured by Medicare, ratherthan paying for services as needed.

It should be noted that the NBMS does not suggest any fees for services associatedwith an Annual Administration Plan, since the breadth of services that could becovered under this plan could be quite large and varied based on individualpractice. In developing fees for an annual administration plan, physicians shouldbe mindful of the College policy, and take into account the factors in their practicethat will determine the value of fees for non-insured services.

The following is an excerpt from the College of Physicians and Surgeons of NewBrunswick Guidelines

It is acceptable for a physician to bill a patient on an annual basis for uninsuredservices, subject to the following conditions:

• The contract between physician and patient must cover a period of not lessthan three months nor more than one full year.

• The contract must accurately and clearly show in writing the services that arecovered by the annual composite fee and those that are not included. Patientshave the right to ask their doctor about any charge they do not understand.

• The contract must also show the fees for each uninsured service if paid for onan individual basis.

• The contract and fees may vary from physician to physician and within grouppractices according to the services provided. Physicians may be guided by thePhysician's Guide to Direct Billing from the New Brunswick Medical Society.

• A copy of these rules must be given to the patient, and the patient mustindicate acceptance of this form of paying for uninsured services before beingbilled the annual fee.

• Patients must retain their choice of paying the annual fee or being billed on anindividual item by item basis.

• Acceptance or continuation of care by a physician of an individual patientcannot be conditional on the patient agreeing to the annual administrativefee.

• Under College regulations, it is improper to charge a patient simply for beingavailable for telephone advice or any other service.


Appendix DMedical Chart Transfer

Date

Dr. ________________________

Address

RE: MEDICAL CHART TRANSFER

Patient: (Name Here)

Dear Doctor,

Thank you for taking over the medical care of this patient. The signed request forthe transfer of medical records was recently received in our office. As you know,the CMPA discourages the transfer of original records, but a copy of the chart willbe forwarded to your office.

The fee charged for this service varies depending on the complexity of the chart.To cover costs of chart preparation and mailing, your new patient is responsiblefor forwarding $_________ to this office at the above address.

Sincerely,

Dr. (Name here)


Sample Out-of-Country Consent Form

GOVERNING LAW

a) I hereby agree that the relationship between me and______________________________________________________ (as well asher/his agents, delegates, employees, and any physicians and other independenthealth care practitioners providing medical care or other health care and treatmentto me, or in association with______________________________________________________), includingwithout limitation any medical or other health care and treatment provided to me, and

b) the resolution of any and all disputes arising from or in connection with thatrelationship, including any disputes arising under or in connection with thisAgreement,

shall be governed by and construed in accordance with the laws of the Provinceof New Brunswick and the laws of Canada applicable therein.

JURISDICTION

I hereby acknowledge that the medical or other health care and treatment Ireceive from ____________________________________________ will beprovided in the Province of New Brunswick, and that the courts of the Province ofNew Brunswick shall have exclusive jurisdiction to hear any complaint, demand,claim, proceeding or cause of action, whatsoever arising from or in connectionwith that medical or other health care and treatment, or from any other aspect ofmy relationship to ____________________________________________.

Date ______________________________

___________________________________ ______________________________

Name of Patient (please print) Signature of Patient / Substitute decision- maker on behalf of patient


(Physician in private practice) OR (health care organization)




Request to Appear in Court

Date

To

Re: Request to appear in court

Client

Court date

The summons to appear in court regarding your client named above was receivedtoday. This letter is written to confirm that I will make appropriate arrangements tobe available for court appearance on that date.

Please be advised that my medicolegal fees for case preparation is$___________ per hour, regardless of whether this matter proceeds to court. Also,court attendance will be billed at $_____ per hour, with a $_________ minimumcharge per day. If this case is settled prior to court action, or it is otherwisedecided that my appearance in court that day is no longer needed, I will requirenotification of this a full 24 hours prior to the proposed court date and time.Otherwise, the minimum charge of $____________ will apply. Early notification ofcancellation is encouraged to minimize medicolegal charges.

If you have any questions regarding this matter, I may be contacted at the addressand phone number above.

Sincerely,

Dr. (Name here)


Third Party Requested Report

Dear (Third Party),

Re: Request for (type of report) on (name of person)

This is to acknowledge your (date) request for this report. The cost of providing thisinformation is not covered by Medicare as an insured service. My fee for thisservice is $__________.

Please acknowledge your acceptance of this fee by signing a copy of this requestand returning it by mail or fax. The report will then be prepared and sent to you.Thank you kindly.

Dr. (Sending Physician)

Request for Medical Information

TO WHOM IT MAY CONCERN

Date

Your request for medical information regarding one of my patients was recentlyreceived in this office. Unfortunately, the payment limitation mentioned in yourrequest has delayed the preparation of this information.

Please be advised that my standard charge for this type of medical form is$__________, plus $__________ per page of photocopied material.

If you would like us to proceed, please resubmit your request with revised paymentauthorization.

Sincerely,

Dr. (Name here)


Specific Arrangements with a Lawyer

Date

Address

RE: Request for (Type of report) on (Name of Patient)

Dear (Name of Lawyer)

As discussed on (Date), your request for a (type of report) for (Name of Patient) hasbeen received in our office on (Date). My fee for this will be $ _________. Otherassociated costs, which may be incurred, are listed below.

Court time per hour $___________

Waiting and/or travel time per hour $___________

Photocopying $___________

Typing $___________

Preparation Time $___________

Payment for the above services will be expected within two weeks of my claimbeing submitted.

In the event that payment is not received on time, an additional ___% will beadded each month for overdue accounts.

Unless you advise me to the contrary in writing within two weeks of the date of thewriting of this letter, I will assume that these payment arrangements are satisfactory.Thank you kindly.

Dr. (Sending Physician)


Appendix EPreparing Medico-Legal Reports:Guidelines for PhysiciansBy CMPA General CounselThe following is a reproduction of an Information Sheet produced by theCanadian Medical Protective Association (CMPA) in May 2001 and revised inJuly 2008. It has been reprinted with permission from CMPA.

You may be requested by a lawyer to provide a medical report for legal purposes.Such requests generally fall into three categories:

1. Report of treating physician

The most common request is for a report on the condition of a patient you aretreating (or have treated). The patient's lawyer will use this report to substantiatethe client's medical disability, treatment and prognosis. It may be presented to aninsurance company in the course of settlement negotiations or to a Court in theevent that the claim is not settled.

2. Independent defence medical examination

A lawyer may ask you to conduct an independent medical examination in apersonal injury lawsuit. You will be asked to examine a plaintiff who is claimingcompensation for personal injuries and to report on the plaintiff's current status,physical limitations and prognosis. This report will be used by the parties involvedin the litigation and by the Court as a basis for assessing compensation. You mayalso be asked to perform an independent medical examination to help an insurerevaluate the extent of an injury or to help a Worker's Compensation Boarddetermine the extent of a disability.

3. Expert opinion

In medical malpractice actions, you may be asked by either side to provide areport addressing the question of whether a treating physician's medical care ofthe plaintiff was in compliance with professional standards.


Are you obligated to prepare a report?

1. Report of treating physician

You are under a professional obligation to provide a report on your own patient'smedical condition. You should insist that the request be in writing and specify thepurpose for which the report is requested. You should also insist on a writtenauthorization, signed by the patient, for the release of this information to theperson requesting it.

You are entitled to a reasonable fee for the preparation of this report.

The Supreme Court of Canada clarified in 1992 that, where there is adoctor/patient relationship, the patient is entitled, for a reasonable fee, to obtaina copy of any records concerning his/her medical treatment in the physician'schart, including any consultants' reports. Privacy legislation now provides patientswith specific rights of access to their personal health information, the scope ofwhich may differ from jurisdiction to jurisdiction. The legislation also prescribes feestructures relevant to access requests.

On occasion, you may be asked to supply copies of records to your patient, or tohis or her authorized representative, with or without an accompanying request for amedico-legal report. Upon receipt of such a request and an appropriate writtenauthorization from the patient, you should forward copies of the relevant recordsunless there is a valid concern that information in the records may cause harm tothe patient or a third party, or if another exception provided by privacy legislationapplies. You must be prepared to prove that there is a legitimate basis upon whichto justify the refusal. Members should seek advice from the CMPA if they are unsurewhether certain information in the record should be disclosed and what provisionsof applicable privacy legislation in their province or territory govern the request.

Without a request or authorization from your patient, you should not release anyinformation from or copies of patient records unless you are required or permittedto do so by law. For example, you may receive a Court Order requiring you toproduce information or you may have to do so pursuant to a statutory requirementsuch as reporting of child abuse or compliance with a College investigation. Youshould seek advice before disclosing any information if you are unsure whetherthere is legal authorization for the disclosure.

2. Independent defence medical examination

It is your personal judgment as to whether you wish to be retained to examine aclaimant as an independent medical expert. If you do so, you should carry out athorough examination including history, physical exam, appropriate tests, etc. andreport fairly and objectively on your findings and conclusions.


3. Expert opinion

Again, this is a matter of choice and there is no obligation to act as an expert.However, many physicians feel a professional obligation to do so (for either side).The CMPA endorses this view.

Before acting as an expert, you should be satisfied that you have the specificexpertise the matter requires and that you have no actual or potential conflict ofinterest. For example, it would not be advisable to be an expert witness for thedefence when either you or your colleagues at the same institution are or havebeen one of the plaintiff's treating physicians. As an expert, you should ensure thatyou have received and carefully reviewed all the required documents so that youare aware of all relevant facts on which to base your opinion. These documentsshould include the pleadings, all relevant medical records of the plaintiff'streatment and transcripts of the evidence from Examinations for Discovery.

You should understand that the purpose of your report and your opinion is to assistthe Court in determining the standard of care that the defendant physician wasexpected to meet at the time the care was provided.

Suggested format for a medico-legal report

Organize your report, using headings where possible. For example:• Address the report to the lawyer or individual who requested it, never "To

Whom It May Concern".• Refer to the purpose for which the report is prepared, e.g., "You have

asked me to assess Mr. Jackson and to answer your questions about hiscurrent medical situation and prognosis..."; or, in a medical negligence case,"You have asked me to review and comment on the standard of medical carein the spinal surgery carried out by Dr X."

• State your credentials and experience in one or two paragraphs. A résuméwill likely have to be supplied before testifying at trial, but a brief summary ishelpful in a report. For example, "I have practised as an orthopaedic surgeonin the City of Sawbones for the last 30 years and was, until recently, Chief ofSurgery at the Sawbones General Hospital and former Chairman of theDepartment of Surgery at the Faculty of Medicine, University of Sawbones."

• Enumerate specifically what documentation you have reviewed to preparethe report. Ideally, this should be a complete list of the medically relevantmaterials available at the time your report was prepared. Again, ensure youhave all relevant documentation, and if not, communicate with the requestingparty.

• State any assumptions used in preparing your report and include anyphotographs, diagrams, calculations or other research data on which youhave relied.


• Outline the relevant patient history.• Describe your examination of the patient and functional enquiry if you

have in fact examined the patient.• Summarize and conclude. This will normally involve your opinion as to the

patient's current condition, degree of disability and the cause of same, andprognosis.

In a medical negligence claim you will need to identify and comment on thedeficiencies, if any, in the medical care rendered by the physician(s) in questionand, of equal importance, state your opinion as to whether any deficiencies in thecare have caused any direct harm or detriment to the patient. A medicalnegligence claim cannot be sustained unless a plaintiff is able to establish that oneor more of the defendant physicians have failed to meet a recognized professionalstandard of care and that the breach of professional standards has actuallycaused harm to the patient.

Similarly, in a personal injury action, the report should address whether and towhat extent the patient's complaints are caused by the accident.

While medical terminology is normally necessary, an effort to writecomprehensibly for educated laypersons (lawyers and judges/juries) is veryhelpful. Unduly technical discussions, understandable only to experts, are of limiteduse in legal proceedings. Except in the case of "progress reports" provided bytreating physicians, the medical report must address all the material issues thatmay be expected to be addressed by the expert in Court. For this reason, it isoften helpful for the expert to discuss this content in advance with the lawyer whohas requested the report. The report should be printed on the physician's personalstationery or that of the university or facility in which the physician practises.

Common problems with medico-legal reports

Experience has shown that avoiding certain practices in conducting a medico-legal examination and in report writing can optimize your contribution to the legalprocess and avoid difficulties with the litigant or the Court. Here are someproblem areas you may wish to avoid:

• Avoid making critical comments to or debating issues with a patient whenperforming an independent medical examination. Patients in this situationare often defensive and inclined to take critical comments in a negative lightand to retaliate by writing letters of complaint.


• Avoid words or actions that may appear to be insensitive. Take the utmostcare in discussing matters relating to a patient's ethnic background, religiousaffiliation, sexual preferences, language abilities or family history. Wherethese are appropriate subjects for discussion, indicate to the patient yourpurpose in making such enquiries. This will help to avoid misunderstandings.

• Avoid using the phrase "dictated but not read" on your letter, andallowing anyone else to sign it. Sign the report yourself after a carefulproofreading.

• Avoid mentioning your fee in the report. Medico-legal reports are usuallyfiled with the Court. You therefore do not want to have something to thiseffect as the last line of your report: "My fee for this report is $750 and I willexpect payment before its release." Also, your fee and the time it reflectsprovide ammunition for cross-examination. Your fee and payment terms canbest be discussed before you agree to act as an expert or independentmedical assessor.

• Avoid making overtly pejorative references to the patient in a medicalreport. For example, a psychiatric report stating, "This patient exhibits a rigidTeutonic personality" calls your objectivity into question and can undermine thecredibility of your report.

• Avoid comments about the patient's socio-economic status. One sometimessees broad-brush references to a patient's attitude being typical of the views ofcertain groups, e.g., "This man and his siblings have subsisted on welfare andhe may see this injury as an opportunity for secondary gain." This may leadothers to question your objectivity and doubt the credibility of your report.

• Avoid stating legal conclusions (i.e., who's at fault) in your report. Amedico-legal report may not be admissible if it unduly goes into the cause ofthe accident and states whose fault the accident was. Do not state or quotethe patient as stating anything like, "The patient's vehicle was sideswiped by adrunk driver who was speeding in the opposite direction."

• Avoid making overt statements or offering specific conclusions on issues ofcredibility. It is the function of the trier of fact (the judge or jury) to decide whoto believe. It is seldom helpful to label someone a "malingerer" or to assert thatsomeone is acting fraudulently or is lying. It will normally suffice to set out thefacts that may lead to that conclusion.

• Avoid "borrowing" the words of others. If your report involves your relianceon other physicians' reports, say so, and properly attribute any quotes fromthem. At trial, it can be very embarrassing to find that portions of the text of amedico-legal report are in fact unattributed quotations from another physicians'examination or analysis.


• Avoid reference to insurance in personal injury actions (other thandiscussing no-fault or rehabilitation benefits). When in doubt, talk to theparty requesting the report. Juries are not supposed to be told that thedefendant is insured. They should not learn this indirectly through your report.

• Avoid criticism of other physicians or health care providers except whenproviding an objective opinion about standards when asked to do so in thecontext of a medical malpractice case, or other matter involving professionalstandards. Such gratuitous remarks can lead to mutual recriminations and maycast doubt on the quality of your report.

• Avoid lengthy and/or repetitious reports. The length of a report will ofcourse vary with the complexity of the matter. However, overly lengthy reports(10 to 15 pages) are seldom helpful and should be avoided.

• Avoid making corrections to reports at a patient's request unless you aresatisfied the correction is warranted. Patients sometimes improperly requestthat reports be changed when they realize the implications of what they mayhave told you. However, it can be embarrassing if your office chart recordscertain information given by a patient and your medico-legal report containsconflicting information.

• Don't be reluctant to be as helpful as possible with respect to a patient'sprognosis. To compensate a personal injury victim, a Court must make certainassumptions about the patient's future. They do this by deciding what willoccur on the balance of probabilities (i.e., what is the most likely scenario).An expert's views on this subject are crucial, even though it may seem to thephysician to be "educated guessing". Medical standards of proof and ofcausation do differ from legal standards. Our system depends on guidancefrom experts concerning future events.

Most misunderstandings concerning medico-legal reports can be solved indiscussion with the party who requested the report. Be aware that your report willbecome available to many people. You will want to ensure that your commentsare professional, accurate, unbiased and objective.

Members who doubt the propriety of rendering a report or their right to decline toprovide a report can contact the CMPA for advice.

CMPA 2008. All reproduction rights are reserved.


Documents

Physicians’ Guide to Direct Billingregarding this guide. Contact the New Brunswick Medical Society (NBMS) by mail at 21 Alison Blvd, Fredericton NB E3C 2N5; by telephone at 506-458-8860